Provider Demographics
NPI:1871084632
Name:BAKOUETILA, MARYSE EMMERENCIA (MD)
Entity type:Individual
Prefix:DR
First Name:MARYSE
Middle Name:EMMERENCIA
Last Name:BAKOUETILA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10902 SHETTLESTON DR
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:TX
Mailing Address - Zip Code:77407-2809
Mailing Address - Country:US
Mailing Address - Phone:936-649-2520
Mailing Address - Fax:
Practice Address - Street 1:2021 N MACARTHUR BLVD STE 350
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75061-2217
Practice Address - Country:US
Practice Address - Phone:972-817-1600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-28
Last Update Date:2021-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXT3586207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine